This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity.
This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM. She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes. There was no speech impairment, no involvement of the face or leg, and no associated headache. These symptoms completely returned to normal. She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities. About 2 days later, she again had a similar spell. She has not had any further episodes since that time.
Patient's history is significant for hypertension since age 35. She had no previous history of heart disease or diabetes. Two years ago she was seen by Dr. Smith for left putamen hemorrhage. Patient was also found to have right meningioma arising near the petrous region. She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly. She could not recall whether either eye was affected or if this was the right peripheral vision. The last such episode was about 4 months ago.
This past winter she also had about a 2-week period when the right foot seemed to drag. There has been no recent head injury, and there is no prior history of seizures.
Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion. No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion. Calcified plaque was also noted in the left carotid bulb. Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia. There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma. This is basically unchanged from the previous scan.
Past Medical History: No serious illnesses.
Operations: 1. Hysterectomy and bladder repair
2. Bilateral blepharoplasty
3. D&C times 4
Medications: 1. Hytrin, 5 mg, one daily
2. Lozol, 2.5 mg, one daily
Tobacco: Does not smoke
Education: Bachelor's degree
Review of Systems: No recent head trauma, blackout spells, or seizures; no recent problems with headaches
Eyes: As noted
Cardiovascular: Negative except for hypertension
Endocrine: No diabetes or thyroid problems
Musculoskeletal: Some arthritis, both hands
Family history: Mother deceased from heart disease; father had multiple strokes; two brothers, one with polio; three children whose health is good
Physical Examination: Very pleasant elderly female, in no distress at this time
Vitals: Blood pressure is 140/84; pulse, 90; 150/90
Left arm sitting position
Skin: No skin lesions present
Nodes: No lymphadenopathy
Chest: Clear to auscultation
Cardiac: Reveals a regular rhythm; I did not hear any murmurs or gallops
Abdomen: Soft, no masses
Higher cortical function: Intact; speech is fluent
Cranial nerves II-XII: Intact; pupils are equal, reactive to light both direct and consequently; confrontation fields are intact; funduscopic exam was normal; ocular sensation is intact; there is no facial paresis or droop
Reflexes: 1/1 throughout; plantar responses are downgoing bilaterally
Motor/tone/strength: Felt to be normal throughout with particular attention paid to the left upper extremity
Sensory: Reveals no sensory deficits, again with attention paid to the left upper extremity
Gait: Reveals no abnormalities; she is able to walk on heels and toes without difficulty; tandem walk is normal; Romberg is negative
Impression: (1) recurrent episodes of left upper-extremity paralysis and numbness; subclavian steal syndrome (Moderate MDM)
Plan: Extensive neurological workup
CPT Code: ____________________